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Zaria Rendon

Brown Sugar LLC

License # COS-FT-10180612

3620 SE Powell Blvd Suite 203 Portland, OR 97202

 

 

The State of Oregon requires service providers to screen all clients prior to performing a service, and to keep updated contact information on file incase of a positive COVID-19 case associated with the business. Public health may need the business to provide this information for a contact tracing investegation. Unless otherwise required this information can be destroyed 60 days after appointment.  This will be a requirement before every appointment. If you answer yes to any of the following questions you will have to reschedule your appointment for a further date. If you have had symptoms or have been diagnosed with COVID-19, or have been in contact with anyone with the symptoms or COVID-19 you must wait until your symptoms have resolved and you have waited atleast 14 days. Clients with a fever will also be denied service and will have to wait atleast 72 hours after fever and symptoms have been resolved without medication.

 

I understand the COVID-19 virus has a long incubation period during which carriers can be asymptomatic. Our determination to service clients is based on present health conditions.


I understand that the inability for both myself and my esthetician to be socially distanced during my appointment puts me at risk for person to person transmission. I knowingly and willingly consent to treatment despite the COVID-19 social distancing climate.


I understand that this business and my esthetician cannot be held liable for any exposure to the virus or any other contagion caused by misinformation or the health history provided by each client.


By submitting this form you agree to each above statements and release “Brown Sugar LLC” and Zaria Rendon from any and all liability for the unintentional exposure or harm due to COVID-19. Your esthetician of this facility agrees that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.


First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Do you have any of the following symptoms: worsening cough, fever, or shortness of breath?*
No
Yes
Have you been in close contact with anyone with these symptoms or anyone who has been diagnosed with COVID-19 in the past 14 days?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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